2021-06-03T17:45:02-05:00 2021-01-31 410746749 CLIFTONLARSONALLEN LLP 8390 EAST CRESCENT PARKWAY SUITE 300 GREENWOOD VILLAGE CO 80111 990 2020-02-01 840743432 CLINICA CAMPESINA FAMILY HEALTH SERVICES CLIN 3036504460 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 SIMON SMITH PRESIDENT & CEO 3036504460 2021-06-03 1 SIMON SMITH 999009999 SARAH HINTZ P00492291 3037795710 2021-06-03 3 AAL1 IAL1 2020 2022-09-23 18:48:47Z CLINICA FAMILY HEALTH SIMON SMITH 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 58962634 0 X WWW.CLINICA.ORG X 1977 CO PROVIDE HIGH-QUALITY, CULTURALLY APPROPRIATE CARE TO LOW-INCOME AND OTHER UNDERSERVED PEOPLE. 12 12 718 15 0 0 18662293 21923500 42208141 36236288 165218 172410 434287 630436 61469939 58962634 6492 264596 0 0 46834807 41648052 0 0 578464 16521051 15448088 63362350 57360736 -1892411 1601898 43271577 46990882 13481638 15786925 29789939 31203957 X TO BE THE MEDICAL, BEHAVIORAL HEALTH AND DENTAL CARE PROVIDER OF CHOICE FOR LOW-INCOME AND OTHER UNDERSERVED PEOPLE IN SOUTH BOULDER, BROOMFIELD AND WEST ADAMS COUNTIES. OUR CARE SHALL BE CULTURALLY APPROPRIATE AND PREVENTION FOCUSED. OUR VISION IS TO ASSURE THAT EVERY LOW-INCOME AND OTHER UNDERSERVED PERSON IN THESE AREAS HAVE ACCESS TO HIGH-QUALITY, PREVENTATIVE MEDICAL, BEHAVIORAL HEALTH AND DENTAL CARE. 0 0 45064952 264596 36236288 FOR THE FISCAL YEAR ENDED JANUARY 31, 2021, CLINICA PROVIDED 196,797 MEDICAL VISITS, 44,124 DENTAL VISITS, 31,646 BEHAVIORAL HEALTH VISITS, 2,010 REGISTERED DIETICIAN VISITS, AND 44,124 CASE MANAGEMENT VISITS. 45064952 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 0 1 20 0 1 718 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 CO X BRIAN JOHNSTON 3036653036 1735 S PUBLIC ROAD LAFAYETTE CO 80026 W DOUGLAS JONES CHAIR 0.10 0.00 X X 0 0 0 CHERLYN MARRIOT VICE CHAIR 0.10 0.00 X X 0 0 0 HEATHER ELKINS SECRETARY 0.10 0.10 X X 0 0 0 ELLA PADILLA TREASURER 0.10 0.00 X X 0 0 0 MATTHEW ANTUSH DIRECTOR 0.10 0.00 X 0 0 0 INEZ BUGGS DIRECTOR 0.10 0.00 X 0 0 0 YULIA HERNANDEZ DIRECTOR 0.10 0.00 X 0 0 0 EDSON HERNANDEZ DIRECTOR 0.10 0.00 X 0 0 0 MAYRA MARTINEZ DIRECTOR 0.10 0.00 X 0 0 0 HEIDY ORDONEZ DIRECTOR 0.10 0.00 X 0 0 0 LIZANDRO GONZALEZ DIRECTOR 0.10 0.00 X 0 0 0 CAROLINA FLORES MANROSS DIRECTOR 0.10 0.00 X 0 0 0 SIMON SMITH PRESIDENT & CEO 39.00 1.00 X 228190 0 41588 BRIAN JOHNSTON CFO 39.00 1.00 X 116568 0 30728 KAREN FUNK CHIEF MEDICAL OFFICER 40.00 0.00 X 278583 0 49717 AN NGUYEN CHIEF DENTAL OFFICER 40.00 0.00 X 192659 0 28178 ALEX BULKACZ PHYSICIAN 40.00 0.00 X 235127 0 37604 BREANNA TOMLIN PHYSICIAN 40.00 0.00 X 235327 0 29670 PHILIP KEPPELER PHYSICIAN 38.00 0.00 X 266158 0 53437 MICHELLE DRURY PHYSICIAN 40.00 0.00 X 229080 0 46995 ANGELA FRYER PHYSICIAN 40.00 0.00 X 236379 0 48332 2018071 0 366249 66 0 1 0 OHIO SHARED INFORMATION SERVICES 8790 GOVERNORS HILL DR 202 CINCINNATI OH 45249 SOFTWARE SUPPORT SERVICES 882163 MOJOS CLEANING SERVICES 8330 E 124TH PL THORNTON CO 80602 JANITORIAL SERVICES 329400 TECHNICAL MOMENTUM 5197 S VERSAILLES ST AURORA CO 80015 IT SERVICES 232128 DENVER HEALTH AND HOSPITAL AUTHORITY 777 BANNOCK STREET DENVER CO 80204 NURSE LINE SERVICES 202983 NEXTGEN HEALTHCARE 18111 VON KARMAN AVENUE IRVINE CA 92612 CLAIMS PROCESSING 175015 12 20485122 1438378 1962859 21923500 PATIENT SERVICE REV. 621110 34068465 34068465 PHARMACY REVENUE 621110 2167823 2167823 36236288 172410 172410 OTHER REVENUE 900099 630436 630436 630436 58962634 36236288 0 802846 260609 260609 3987 3987 868125 154849 713276 34639431 29228220 5203849 207362 3607929 2956246 633520 18163 2532567 2075122 444696 12749 27606 6694 18236 2676 81108 19667 53578 7863 1786427 1196791 569644 19992 99612 21278 71418 6916 1181362 286453 780377 114532 1479614 358773 977394 143447 2680910 1693050 986060 1800 24016 11384 12574 58 21467 10176 11239 52 364177 208420 155757 1533417 1012055 521362 192573 94746 92636 5191 MEDICAL SUPPLIES 5172969 5172969 MISCELLANEOUS 208455 50546 137700 20209 EDUCATION 179559 87795 91175 589 DUES & SUBSCRIPTIONS 163145 39559 107769 15817 251671 115563 135060 1048 57360736 45064952 11717320 578464 5934696 3108789 153671 7994606 1957842 1346756 5030924 5008416 12469400 12469400 22249 27845 416679 705277 29910467 13721914 17180864 16188553 105252 141240 43271577 46990882 5297808 7123203 332472 465519 6633941 6438868 1217417 1759335 13481638 15786925 X 28941528 30278578 848411 925379 29789939 31203957 43271577 46990882 X 1601898 -187880 X X 0 1 X 1 1 1 X 17522367 19150082 18761551 18662293 21921691 96017984 17522367 19150082 18761551 18662293 21921691 96017984 96017984 1064 130 775 165115 172410 339494 468732 292881 1269471 434287 630436 3095807 99453285 185656257 0.96550 0.96810 X SCHEDULE A, PART II, LINE 10, EXPLANATION OF OTHER INCOME: OTHER INCOME RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 13942 13942 56768325 56782267 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 13228 13527 13770 13942 54467 250000 250000 250000 250000 1000000 1500000 3835786 3835786 15747619 6349493 9398126 10286092 7372421 2913671 40970 40970 16188553 DUE TO RELATED ORGANIZATION 908876 INTEREST RATE SWAP AGREEMENT 850459 1759335 X 59493812 992059 858815 1850874 57642938 1319696 1319696 58962634 58092186 992059 992059 57100127 260609 260609 57360736 PART X, LINE 2: THE ORGANIZATION QUALIFIES AS A TAX-EXEMPT CORPORATION DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION IS NOT A PRIVATE FOUNDATION, AND CONTRIBUTIONS TO THE ORGANIZATION QUALIFY AS CHARITABLE TAX DEDUCTIONS BY THE CONTRIBUTOR. THE ORGANIZATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX PROVISIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE ORGANIZATION'S FINANCIAL STATEMENTS. THE ORGANIZATION IS NOT AWARE OF ANY ACTIVITIES THAT WOULD JEOPARDIZE ITS TAX-EXEMPT STATUS OR AWARE OF ANY ACTIVITIES THAT ARE SUBJECT TO TAX ON UNRELATED BUSINESS INCOME OR EXCISE OR OTHER TAXES. PART XI, LINE 2D - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTIONS FOR OPERATIONS 858,815. PART XI, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT 187,880. CONTRIBUTIONS WITH DONOR RESTRICTIONS 935,783. CAPITOL CONTRIBUTIONS 196,033. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTION FOR RELATED ORGANIZATION 260,609. 1 CLINICA HOLDING COMPANY 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 823052286 501(C)(3) 260609 N/A N/A CONTRIBUTE ASSETS TO CLINICA HOLDING COMPANY 1 0 PART I, LINE 2: CLINICA HOLDING COMPANY IS A RELATED CONTROLLED ORGANIZATION WITH COMMON FINANCIAL CONTROL. X X X X 0 0 0 0 0 0 0 0 0 KAREN FUNK CHIEF MEDICAL OFFICER 278583 0 0 0 0 0 26992 0 22725 0 328300 0 0 0 PHILIP KEPPELER PHYSICIAN 266158 0 0 0 0 0 25694 0 27743 0 319595 0 0 0 ANGELA FRYER PHYSICIAN 236379 0 0 0 0 0 24463 0 23869 0 284711 0 0 0 MICHELLE DRURY PHYSICIAN 229080 0 0 0 0 0 20799 0 26196 0 276075 0 0 0 ALEX BULKACZ PHYSICIAN 235127 0 0 0 0 0 27275 0 10329 0 272731 0 0 0 SIMON SMITH PRESIDENT & CEO 228190 0 0 0 0 0 20439 0 21149 0 269778 0 0 0 BREANNA TOMLIN PHYSICIAN 235327 0 0 0 0 0 19491 0 10179 0 264997 0 0 0 AN NGUYEN CHIEF DENTAL OFFICER 192659 0 0 0 0 0 20390 0 7788 0 220837 0 0 0 X 38986 1962859 FMV 0 0 1 0 PART I, COLUMN (B): THE NUMBER OF ITEMS RECEIVED IS REPORTED IN PART I. FORM 990, PART VI, SECTION A, LINE 1 THE GOVERNING BOARD OF DIRECTORS SHALL HAVE THE POWER TO DESIGNATE AND APPOINT ONE OR MORE COMMITTEES, EACH OF WHICH SHALL CONSIST OF TWO OR MORE DIRECTORS, WHICH COMMITTEES SHALL HAVE SUCH AUTHORITY AS DELEGATED BY THE BOARD, EXCEPT THAT NO SUCH COMMITTEE SHALL HAVE THE AUTHORITY TO AMEND, ALTER OR REPEAL THE BYLAWS; ELECT, APPOINT OR REMOVE ANY OFFICER OR DIRECTOR OF THE CORPORATION; AMEND THE ARTICLES OF INCORPORATION; RESTATE THE ARTICLES OF INCORPORATION; ADOPT A PLAN OF MERGER OR ADOPT A PLAN OF CONSOLIDATION WITH ANOTHER CORPORATION; AUTHORIZE THE SALE, LEASE, EXCHANGE, OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY AND ASSETS OF THE CORPORATION; AUTHORIZE THE VOLUNTARY DISSOLUTION OF THE CORPORATION OR REVOKE PROCEEDINGS THEREFOR; ADOPT A PLAN FOR THE DISTRIBUTION OF ASSETS OF THE CORPORATION; AND/OR AMEND, ALTER OR REPEAL ANY RESOLUTION OF THE BOARD OF DIRECTORS WHICH BY ITS TERMS PROVIDES THAT IT SHALL NOT BE AMENDED, ALTERED, OR REPEALED BY SUCH COMMITTEE. FORM 990, PART VI, SECTION A, LINE 4 SECTION 3.4 OF THE BYLAWS WAS UPDATED TO THE FOLLOWING: DIRECTORS MAY NOT BE CLINIC EMPLOYEES OR IMMEDIATE FAMILY MEMBERS OF CLINIC EMPLOYEES. IMMEDIATE FAMILY MEMBER IS DEFINED AS SPOUSE, CHILD, PARENT OR SIBLING, EITHER BY BLOOD, ADOPTION OR MARRIAGE. A MAJORITY OF DIRECTORS (AT LEAST 51%) SHALL BE PATIENTS OF THE CLINIC, AS REQUIRED BY FEDERAL LAW. PATIENT IS DEFINED AS AN INDIVIDUAL WHO HAS RECEIVED AT LEAST ONE SERVICE IN THE PAST 24 MONTHS THAT GENERATED A HEALTH CENTER VISIT. AT EACH ELECTION OF DIRECTORS, THE BOARD OF DIRECTORS SHALL REVIEW THE COMPOSITION OF THE BOARD AND GIVE DUE CONSIDERATION TO THE REPRESENTATION ON THE BOARD OF DIRECTORS OF THE COMMUNITIES IN WHICH THE CORPORATION HAS CLINIC OPERATIONS AS WELL AS TO FACTORS SUCH AS AGE, SEX, ETHNICITY AND CONSUMER REPRESENTATION TO ASSURE DIVERSITY ON THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS WILL ALSO TAKE INTO ACCOUNT WHETHER IT HAS DIRECTORS WHO HAVE EXPERTISE IN COMMUNITY AFFAIRS, LOCAL GOVERNMENT, FINANCE AND BANKING, LEGAL AFFAIRS, TRADE UNIONS, AND OTHER COMMERCIAL AND INDUSTRIAL CONCERNS, OR SOCIAL SERVICE AGENCIES WITHIN THE COMMUNITY. DIRECTORS NEED NOT BE RESIDENTS OF THE STATE OF COLORADO. NO MORE THAN ONE-HALF OF THE NON-PATIENT BOARD MEMBERS WILL DERIVE MORE THAN 10% OF THEIR ANNUAL INCOME FROM THE HEALTH CARE INDUSTRY. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD OF DIRECTORS REVIEWED THE FORM 990 PRIOR TO IT BEING FILED WITH THE IRS. THE CFO REVIEWED THE FORM 990 AND PRESENTED IT TO THE BOARD'S FINANCE COMMITTEE BEFORE IT WAS PRESENTED TO THE FULL BOARD. THE REVIEW INCLUDED A RECONCILIATION OF THE FORM 990 INFORMATION TO THE DATA IN THE AUDITED FINANCIAL STATEMENTS AND A COMPARISON OF THE DATA TO PRIOR YEAR FINANCIAL STATEMENTS TO CONFIRM REASONABLENESS. FORM 990, PART VI, SECTION B, LINE 12C NEW EMPLOYEES AND BOARD MEMBERS RECEIVE TRAINING AND ARE ASKED TO SIGN A CONFLICT OF INTEREST DISCLOSURE FORM ON THE FIRST DAY OF EMPLOYMENT OR SERVICE, AND THEN ANNUALLY. ALL EMPLOYEES AND BOARD MEMBERS ARE INFORMED OF THEIR OBLIGATION TO IMMEDIATELY REPORT ANY CONFLICTS WHEN THEY OCCUR OUTSIDE OF THE ANNUAL PROCESS. THE COMPLIANCE OFFICER, CFO, AND/OR CEO REVIEWS ANY CONFLICTS IDENTIFIED AND A WRITTEN MANAGEMENT PLAN IS DEVELOPED, SIGNED BY THE EMPLOYEE AND HIS/HER MANAGER, AND REMAINS A PART OF THE EMPLOYEE'S HR FILE. ANY VIOLATIONS OF THE WRITTEN MANAGEMENT PLAN WILL RESULT IN DISCIPLINARY ACTION UP TO AND INCLUDING TERMINATION. NO EMPLOYEE, OFFICER, DIRECTOR OR AGENT OF THE ORGANIZATION CAN PARTICIPATE IN THE SELECTION OF A CONTRACT, INCLUDING PURCHASE ORDERS, OR IN THE ADMINISTRATION OF A CONTRACT, IF A REAL OR APPARENT CONFLICT OF INTEREST EXISTS. ALL SUPPLIERS COMPLETE A SUPPLIER CONFLICT OF INTEREST DISCLOSURE. EXCEPTIONS MAY BE APPROVED BY THE CEO OR CFO. THE EXCEPTION IS DOCUMENTED AND APPROPRIATELY DISCLOSED. MONITORING OF THE CONFLICTS OF INTEREST POLICY IS A STANDARD BOARD OF DIRECTORS MEETING AGENDA ITEM. BOARD MEMBERS IDENTIFY POTENTIAL CONFLICTS OF INTEREST BEFORE THE BOARD MEETING COMMENCES SO THAT THEY CAN BE ADDED TO THE AGENDA. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS' COMPENSATION COMMITTEE DETERMINES THE COMPENSATION OF THE CEO USING AN ANALYSIS OF MARKET SALARIES COMPILED BY THE CHIEF HR OFFICER, USING INFORMATION AVAILABLE FROM THE EMPLOYERS COUNCIL, THE NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS AND THE COLORADO COMMUNITY HEALTH NETWORK. THE DISCUSSION/DELIBERATION IS DOCUMENTED IN THE BOARD'S COMPENSATION COMMITTEE NOTES AND NOTED IN THE BOARD'S MEETING MINUTES. A PAYROLL NOTE DOCUMENTS THE FINAL DECISION AND IS APPROVED BY THE MEMBERS OF THE BOARD'S COMPENSATION COMMITTEE. THE LAST COMPENSATION REVIEW TOOK PLACE IN 2021. THE COMPENSATION OF OTHER OFFICERS IS EVALUATED USING AN ANALYSIS OF MARKET SALARIES COMPILED BY THE CHIEF HR OFFICER, USING INFORMATION AVAILABLE FROM THE EMPLOYERS COUNCIL, THE NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS AND THE COLORADO COMMUNITY HEALTH NETWORK. THE CEO DETERMINES ANY COMPENSATION ADJUSTMENTS AND THE DECISION IS DOCUMENTED IN A PAYROLL NOTE APPROVED BY THE CEO. IN ADDITION, THE ORGANIZATION PERIODICALLY USES AN EXTERNAL COMPENSATION CONSULTANT TO DETERMINE COMPENSATION OF THE CEO, OFFICERS, KEY EMPLOYEES, AND CERTAIN OTHER EMPLOYEES OF THE ORGANIZATION. THE CONSULTANT REVIEWS THE ORGANIZATION'S STRATEGIC OBJECTIVES, RELEVANT POLICIES AND PROCEDURES AND CURRENT COMPENSATION DOCUMENTATION. THE CONSULTANT USES SURVEYS AND OTHER INFORMATION TO DEVELOP UP-TO-DATE MARKET INFORMATION BASED ON THE DETAILED JOB DESCRIPTIONS PROVIDED BY THE ORGANIZATION. THE CONSULTANT WORKS WITH LEADERSHIP TO DEVELOP BASE COMPENSATION SALARY RANGES INCLUDING COST ANALYSIS FOR PROPOSED PAY ADJUSTMENTS TO THOSE SALARIES FALLING OUTSIDE THE RANGE. A COMPENSATION ANALYSIS WILL BE COMPLETED IN 2021. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT -187,880. FORM 990 PART XII LINE 2C THE PROCESS FOR OVERSIGHT AND SELECTION OF AN INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. CLINICA HOLDING COMPANY 1735 SOUTH PUBLIC ROAD LAFAYETTE CO 80026 823052286 PROPERTY HOLDING CO 501(C)(3) LINE 12A, I CLINICA CAMPESINA FAMILY HEALTH SERVICES 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 1 1 1 1 CLINICA HOLDING COMPANY B 260609 CASH CLINICA HOLDING COMPANY K 600000 FAIR MARKET VALUE